Manual for Durable Medical Equipment, Orthotics ...

1 Manual for Durable Medical equipment , Orthotics , Prosthetics & Supplies (DMEOPS) Published by: Medical Services north dakota Department of Human Services 600 E Boulevard Ave, Dept 325 Bismarck, ND 58505 March 2013 FORWARD PURPOSE This handbook has been prepared for the information and guidance of Durable Medical equipment and Medical supply providers who provide items or services to participants in the Department s Medical Programs. Contained in this handbook are both policy and procedures for Durable Medical equipment and Medical supply items and services.

2 This handbook provides information on which items require prior approval and how to obtain prior approval. Providers will be held responsible for compliance with all policy and procedures contained herein. TABLE OF CONTENTS KEY CONTACTS .. 1 STATEMENT OF INTENTION .. 2 PURPOSE OF THE MEDICAID PROGRAM .. 2 DEPARTMENT OF HUMAN SERVICES, Medical SERVICES DIVISION .. 2 INTRODUCTION .. 4 Manual ORGANIZATION .. 4 RESPONSIBILITY FOR 4 PROVIDER ENROLLMENT .. 4 CHANGES IN ENROLLMENT .. 6 CHANGE IN OWNERSHIP .. 6 TERMINATING MEDICAID ENROLLMENT .. 6 PROVIDER REQUIREMENTS.

3 6 PAYMENT FOR SERVICES .. 7 MEDICAID PAYMENT IS PAYMENT IN FULL .. 7 UTILIZATION MANAGEMENT .. 8 CLAIMS REVIEW .. 8 GETTING QUESTIONS ANSWERED .. 8 GENERAL COVERAGE PRINCIPLES .. 9 SERVICES FOR CHILDREN .. 9 PROVISION OF SERVICES .. 9 PROVIDER DOCUMENTATION ..10 CERTIFICATE OF Medical NECESSITY ..11 RENTAL/PURCHASE ..11 REPAIRS ..12 NON COVERED equipment AND SUPPLIES ..13 PRIOR AUTHORIZATION ..14 PRIOR AUTHORIZATION FORM COMPLETION GUIDE ..16 PRIOR AUTHORIZATION ADJUSTMENT/COMPLETION GUIDE ..18 QUANTITY LIMITATIONS: ..20 PRESCRIPTION REQUIREMENTS.

4 20 EXCEPTION REQUESTS ..21 CODING ..21 COORDINATION OF BENEFITS .. 22 WHEN CLIENTS HAVE OTHER COVERAGE ..22 IDENTIFYING AND VERIFYING ADDITIONAL COVERAGE ..22 PRIVATE HEALTH CARE PLANS AND THIRD PARTY PAYERS ..22 RECIPIENT COOPERATION WITH TPL BILLING ..23 INSTRUCTIONS TO CHECKING CLIENT ELIGIBILTY .. 24 VERIFY OPERATIONAL STEPS ..24 BILLING PROCEDURES .. 25 CLAIM FORMS ..25 ELECTRONIC CLAIMS ..25 PAPER USING THE MEDICAID FEE SCHEDULE ..27 MISCELLANEOUS/NOT OTHERWISE SPECIFIED HCPCS CODES ..27 CLAIM INQUIRIES ..27 THE MOST COMMON BILLING ERRORS AND HOW TO AVOID THEM.

5 28 THIRD PARTY PAYMENT BILLING INSTRUCTIONS ..28 REMITTANCE ADVICE REBILLING AND ADJUSTMENTS ..31 WHAT IS RECIPIENT LIABILITY ..31 TAKING RECIPIENT LIABILITY (RL) AT THE TIME OF WHAT IS THE FUNCTION OF SURS .. 32 DESK AUDITS ..32 KEY POINTS ..32 BILLING TIPS ..32 DEFINITIONS AND ACRONYMS .. 34 APPENDIX A PROVIDER ENROLLMENT FORMS .. 38 PROFESSIONAL ..38 PHARMACY ..38 OUT-OF-STATE PROVIDERS ..38 APPENDIX B NON COVERED-NO EXCEPTION ITEMS .. 40 APPENDIX C GUIDELINES .. 44 APNEA MONITOR ..44 ANKLE-FOOT/KNEE-ANKLE-FOOT ORTHOSIS ..44 AFO AND KAFO, CUSTOM.

6 45 BATH/SHOWER CHAIR OR TUB STOOL/BENCH ..46 BILIRUBIN LIGHTS ..46 BLOOD GLUCOSE MONITORS: ..46 BREAST PUMP ..47 CANE/CRUTCHES ..48 CERVICAL TRACTION HOME DEVICES ..48 CHEST WALL OSCILLATING DEVICE (AIRWAY VEST SYSTEM) ..49 COLD THERAPY ..49 COMMODES/CHAIRS ..49 CONTINUOUS PASSIVE MOTION EXERCISE (CPM) ..50 CONTINUOUS POSITIVE AIRWAY DEVICE (CPAP) ..50 CRANIAL REMOLDING ORTHOSIS ..51 ENCLOSED BED ..50 ENTERAL NUTRITION ..50 EXERCISE equipment ..52 EXTERNAL BREAST PROSTHESIS ..52 EXTERNAL INSULIN INFUSION PUMP ..52 EXTERNAL INFUSION PUMP ..54 EYE PROSTHESIS.

7 55 FACIAL PROSTHESIS ..55 FIRST AID SUPPLIES: ..56 HEARING AIDS: ..56 HOSPITAL BEDS ..58 INCONTINENCE GARMENTS (ADULT & YOUTH) ..59 NEBULIZERS: ..59 OSTEOGENIC BONE STIMULATOR ..60 OSTOMY SUPPLIES: ..61 OXYGEN equipment ..61 PARENTERAL NUTRITION ..62 PATIENT LIFTS ..63 PNEUMATIC PRESSURE DEVICES ..63 POWER OPERATED VEHICLE ..63 PRESSURE REDUCING SUPPORT SERVICES ..63 prosthetic DEVICES ..64 PULSE OXIMETER/SUPPLIES ..64 RESPIRATORY ASSIST DEVICES (BIPAP) ..65 SADD LIGHTS ..66 SEAT LIFT MECHANISM ..66 SPEECH GENERATING DEVICE ..66 STANDING FRAME.

8 67 SUCTION PUMPS ..67 SURGICAL DRESSINGS ..68 THERAPEUTIC SHOES/ INSERTS ..70 TLSO/LSO ..70 TRACH CARE KITS ..71 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATORS (TENS) ..71 UROLOGICAL SUPPLIES: ..71 WALKERS/GAIT TRAINERS ..72 WHEELCHAIR -- Manual ..72 WHEELCHAIR -- OPTIONS/ACCESSORIES ..73 WHEELCHAIR -- POWERED BASE ..75 WHEELCHAIR -- SEATING ..75 WOUND THERAPY DEVICES ..76 APPENDIX D DME IN FACILITIES .. 77 APPENDIX E PRIOR APPROVAL ALWAYS REQUIRED .. 81 APPENDIX F LIST OF MODIFIERS .. 82 1 KEY CONTACTS THIRD PARTY LIABILITY For questions about private insurance, Medicare, or other third-party liability: (800) 755-2604 (701) 328-3507 Send written inquiries to: Third Party Liability Unit Medical Services ND Dept.

9 Of Human Services 600 E Boulevard Ave-Dept 325 Bismarck ND 58505-0250 ELECTRONIC CLAIMS For questions regarding electronic claims submission: (800) 755-2604 (701) 328-2325 Fax: 1-(701) 328-1544 PAPER CLAIMS Send paper claims to: Claims Processing Medical Services ND Dept of Human Services 600 E Boulevard Ave Dept 325 Bismarck ND 58505-0250 PROVIDER RELATIONS For questions about recipient liability payments, denials or general claims questions: (800) 755-2604 (701) 328-4030 PRIOR AUTHORIZATION (PA) Mail or fax all requests for prior authorization to: Medical Services Administrator Quality Care/Disability ND Dept.

10 Of Human Services 600 E Boulevard Ave-Dept 325 Bismarck ND 58505-0250 Fax: 1-(701) 328-0370 PROVIDER INFORMATION 2 STATEMENT OF INTENTION Supersedes: north dakota Medicaid DMEOPS ( Durable Medical equipment , Orthotics & Prosthetics, and Medical Supplies) Manual , March 2003, and all changes that have occurred in memorandums. References: Title XIX, Social Security Act; United States Code (USC) 1396-1396v, Subchapter XIX, Chapter 7, Title 42; Code of Federal Regulations (CFR), Chapter IV, Title 42, Subtitle A, Title 45; Administrative Rules of north dakota Title , Chapter 02 Updated: June 2006 Codes, References, Etc.